CONFEDERATE STATES

reach 7.7. It will be remembered that the campaign of 18<j2 was conducted with the utmost vigor, and that the army fought, in quick succession, many sanguinary battles, commencing with that of Williamsburg and ending with that of Fredericksburg; including between these two the battles arouud Richmond, Cedar Mountain, Manassas and Sharpsburg, each of which resulted in a heavy list of casualties to the troops engaged. The mortality from these causes, as might be expected, was not nearly so great during this year as it had been during the

The proportion of these was less than that of last year by 2 per cent.; that is to say, while gun-shot injuries, during the period covered by the report of last year, amounted to 9.8 of the whole number of cases reported; for 18G3, they ouly reach 7.7. It will be remembered that the campaign of 18<j2 was conducted with the utmost vigor, and that the army fought, in quick succession, many sanguinary battles, commencing with that of Williamsburg and ending with that of Fredericksburg; including between these two the battles arouud Richmond, Cedar Mountain, Manassas and Sharpsburg, each of which resulted in a heavy list of casualties to the troops engaged.
The mortality from these causes, as might be expected, was not nearly so great during this year as it had been during the one previous. The mnn had become hardened and better able to resist the influence of climate and exposure, and the battles, which occurred during the year, transpired at a season far more favorable to recoveries. Thus, instead of being crowded together in hastily extemporized hospitals during the intense heats of mid summer, as they were in 1862, the battle of Chancellorsvillej fought early in May, gave to its wounded the benefit of a most delightful and salubrious season for treatment and recovery, while that of Gettysburg, still later, sent ouly to our hospitals the more slightly wounded, leaving the grave cases in the hands of the enemy to die, or to be otherwise accounted for iu a manner not known to our reports.
The surgical operations performed on uie lieid at Ubancellorsville did remarkably well. Generally, the wounded reached the hospitals in this city in a condition favorable to recovery, and as before stated, the excellent condition ol our hospitals seemed to repress all tendency to the prevalence oi erysipelas or gangrene. Indeed, never before or since have they been so entirely free from the presence of these diseases, as they were during the summer aud fall ot this year.?

12
In the hospitals, the mortality from wounds, during the year 1862, amounted to 11.2; in 1863, to 2.3; and this difference is really increased still further in favor of the latter year, by the fact, that the wounded from the battle of Fredericksburg gave most of its mortality to the year 1863, without addiug at all to the number of cases for that year?these having been already embraced in reports for 1862.
The figures, as wc have them in our reports for this year, exhibit 42,885 cases of Wounds treated in hospitals, and 999 deaths?this yields a mortality of 2.3. But, in order to arrive at a more accurate estimate of the proportion really dying from wounds in hospital, it will be well to assume that the number reported from the field were all that were treated in hospitals; and this being 27,200, and the mortality 999, we have a per centage of 3.7, which, it is .believed, approaches nearer the truth.
Adding the number dying in hospitals to those reported1 from the field, we have an aggregate of deaths for the year in field and in hospital, from guu-shot wounds, of 1,728, or 2.4 of the whole number of cases reported.
This, however, is much too small, because it is impossible, as before stated, with our present form of reports, to avoid the frequent multiplication of cases by "transfer, &c. ])uring this year, one case of successful amputation at the hip-joint was reported. It occurred in the persou of James Kelly, private company " B," oGth Pennsylvania, aged 28 and by occupation a farmer. He was wounded April 29th, 1863, near Fredericksburg, sustaining compound comminuted fracture of the femur. Disarticulation, by antero-posterior flaps, was performed the same day on the field He fully recovered, was paroled and sent North July, 14th, 1863. ( Operation -performed by Surgeon E Shippen, U. S. A.) It is proper to remark, also, in this connection, the many successful cases of amputation, especially of the upper-third of the thigh, occurring in our reports. Among them may he mentioned Lieutenant-G-enerals Ewell and Hood, (the latter now General Commanding Army of Tennessee,) both of whom have been restored to duty, in the full vigor of health, with thighs amputated just a little short of the hip-joint. Added to these are many others, of less distinction, it is true, but not the less attesting the skill and ability of Confederate Surgeons in the performance of an operation, regarded heretofore as almost uniformly fatal. Indeed, so much had this come to be regarded the case, that recently an order emanating"from the 154 CONFEDERATE STATES MEDICAL AND SURGICAL JOURNAL. V**ra&r? T' jh ||M|| n, pi mminili??i|i||||?|fM?? lilllWITlUTTTI III |i|H||| ilillM mmillBI'l ml Ml Federal Surgeon-Geuer I forbids such operations on the field, not only at the upper-third, but anywhere along the continuity of the thigh. This question of Conservative Surgery in compound fractures of the femur, is one which is receiving the most earnest attention of military surgeons, and though it has been, to some extend, decided in the I nited States, we Sire obliged, in balancing the merits of the two methods of treatment, to adopt a different opinion. With us the results, as elicited from our r port-?, xhibit a slight pev centagc in favor of the operation itself on the field. Thus, of 77 cases of primary amputation of :Jr t: h, at the upper-third, 40 recovered, and 37 died. letLev of treatment in simitar cases: for, of 2:21 cases, wh' re amputation was not resorted to, TIG recovered.
These results are indeed remarkably favorable; far surpassing, in this way, any heretofore reported or kuown to the profession.
As between the two modes of treatment, the difference in the results is but slight, as shown by the figures given above, and as will be more perfectly understood when the tables annexed shall 1 ex mined Guided, then, by our reports, it may be safely accepted as a rule, that the better plan, in general, is to operate on the field. The greater readiness with which the patient can be transported from the field; the greater ease and comfort realized under these circumstances, when the limb has been removed; the lesser time required in hospital for recovery, would all seem to point to its adoption as the wiser policy. Still, in these and in all other questions of surgical interference, the medical officer should be governed by the peculiar circumstances attending each case.
Many resections were performed during this year; and while in very many instances with results altogether favorable, so far as recovery alone is considered, yet, we are inclined to think, in nearly all cases, leaving limbs of very doubtful utility.
Indeed, when it is considered that these operations arc much more fatal than simple amputations, exposing the patient for a much greater time to the evil influence of hospital atmosphere; involving more frequently, too, attacks of erysipelas, gangrene, nod pyemia, it may be well questioned if our surgeons do not too often resort to them.
The shoulder-joint, we sometimes think, is the only one in which resection promises all the good results claimed for it. In the elbow, if the entire joint be removed, no possible effort of nature can supply the lost motion; and the slight prehenhie power of the lingers, which mny continue, can scarcely atone for the awkWard, Useless and ungainly limb remaining.
Exsection of the knee joint we cannot help regarding as positively reprehensible on the field, and scarcely less so in hospital. But one succesafu\ ease is reported during the year, (Surgeon J. 13. Read;) at last accounts, (September, 186*,) the patient was fully recovered, but with a limb shortened by several inches, and union only ligamentous. Ampu-, tation has been asked for by him, and will be performed as soon as the condition of his health may jnstify it.
One successful case of resection of hip-joint has likewise been reported by .Surgeon J. B. Head, and though the lej will never be of any use, yet it is fair to say, that to this operation may be due the preservation of the patient's life, which might have been more seriously imperilled by disarticulation.
Frequent cases of gun-shot wounds, healing by first intention, have also been reported. It is difficult to understand how this can be so, when all our theories of repair and restoration of lost tissues have been based on inflammatory action, leading, of course, to suppuration and granulation. Still, the evident care and truthfulness which accompany the report of the cases attest the fact beyond all doubt; and it is hoped that future investigations on the part of the Medical Staff will, in time, yield much that is interesting and instructive in this connection. Already, it has been proposed (by Surgeon J. J. Chisolm) to convert all gun-shot wounds into simple incised wounds, by paring the ragged edges, and nicely adjusting the lips by means of sutures or straps, excluding the atmosphere, and thus effecting a cure by absorption and re-modelling, without the aid of suppuration.

TETANUS.
In reviewing carefully all the circumstances connected with gun-shot wounds, as exhibited in the reports before us, it would be singular did we not remark the occasional occurrence of tetanus. This complication of gun-shot wounds, so obscure, so fearfully fatal, and so much to he deplored, is fortunately seldom met with. Indeed, it has always been a source of wonder to all writers ou military surgery that it so rarely occurs. In our reports for 1861, we find that in 1,750 cases of wounds of different characters, t here were thirteen cases of tetanus?0.75, or one case of tetanus in 131 cases of wounds. Of these only three are reported as having ended fatally, giving a ratio of mortality of 2.3, or one death in four eases: a result which clearly proves the inaccuracy of our earlier reports.
In 1862, the consolidated reports from hospitals present 15,971 cases of wound*, uud only 53 cases of tetanus?0.11, or one case of tetanus ia 867 cases of wounds. Of these 53 cases, 28 terminated in death?52.8, about one death in two cases, a much larger"per centage of mortality than in 1861? DUE stilly we nave reason to suspect, very much below the truth. Many ol the cases reported tetanus are, doubtless, mere cases of traumatic spasms, hence such apparently favorable results.
Tetanus was doubtless of more frequent occurrence in our hospitals than would appear from the reports, as it is well known that cases are generally reported under the disease they first enter with, which ordinarily is ""V ulnus Sclopeticum." It is only reccutly that surgeons have been reporting "supervening diseases." In referring to our special reports of gun-shot injuries involving tetanus, covering the whola period of the war up to the present time, aud which are evidently drawn up with great care, we hod 66 cases recorded. Of these, six only recovered, giving a mortality of nearly 91 per cent, Assuming, then, that these constitute the entire number of cases of decided tetanus which have occurred on the whole CONFEDERATE STATES MEDICAL AND SURGICAL JOUJRNAL. number ci' gun-shot wounds treated, (50,775,) we have the proportion of 1 case of tetanus to every SCO cases of gun-shot wound.
McLood, in Lis Surgery of the Crimean War, does not give the proportion of tetanus to wounds, but he says he could only hear of thirteen casts of tetanus in the English army throughout the Crimean war. These were all fatal?with only one exception. In the last East India war, nineteen cases are reported, and only one recovery. Alcock gives the proportion of cases of tetanus to wounds as one in sevcnty-niue. Stromyer states, that during the Schleswig-IIolstein war, the proportion was ,3 in 1,000. In 1830, of 390 cases of gun-shot wound, there was only one case of tetanus in the Hotel Dieu at Paris.
The following tables which exhibit the general results of amputations and resections thus far collected, and carefully prepared from reports throughout the Confederacy: